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Medicare Plan Forms
Medicare Forms
Below are the forms most commonly needed by Medicare plan members. If you do not find the Medicare form you are looking for in this section, please contact our office at 1 (800) 541-8981. TTY users should call 711. From November 15 through March 1 our telephone hours are 8 a.m. to 8 p.m. seven days a week. After March 1 our telephone hours are 8 a.m. to 8 p.m., Monday through Friday, and you may leave a message on Saturdays, Sundays and holidays. We will return your call on the next business day.
| Medicare Member Forms | Description |
|---|---|
| General Forms | |
| SurePay Information and Authorization Form • 2010 (45k PDF) |
Use this form to set up automatic payment of premium from your personal bank account for Regence MedAdvantage (PPO) plans. |
| Prescription Claim Form (62k PDF) | Use this form to submit for reimbursement of covered medications you may have purchased without using your member card. |
| Authorization for Use and Disclosure of Protected Health Information (55k PDF) | Authorization for Regence BlueCross BlueShield of Utah to disclose health information to a designated party for a specific purpose. |
| Application Form for Regence MedAdvantage (PPO) Plans • 2010 (80k PDF) |
Use this form to apply for Regence MedAdvantage (PPO) coverage. Enrollment is subject to eligibility and enrollment or election periods. |
| Short Enrollment Form • 2010 (43k PDF) |
For members upgrading their plan. All pages of this form must be given to inquiring or applying individuals. |
| Prescription Mail-Order Form | |
| Postal Prescription Services (30k PDF) | Use this form for mail order prescriptions from Postal Prescription Services. |
| Grievance and Appeals Forms | |
| Coverage Determination Form (Members) | Members: Use this form for coverage decisions. |
| Coverage Determination Form (Providers) | Providers: Use this form for coverage decisions. |
| Appeal Form (30k PDF) | Use this form to request an appeal to a coverage determination. |
| Complaint Form (30k PDF) | Use this form to file a complaint/grievance with us. |
| Appointment of Representative | Use this form to appoint another individual to act on your behalf. |
Last updated 12/09/2009
M0016_2010 WEB MA FORMS 10/2009
© 2009 Regence BlueCross BlueShield of Utah. All rights reserved. Regence BlueCross BlueShield of Utah is an Independent Licensee of the Blue Cross and Blue Shield Association.
